Medical Coding 1 CH 2-Notes/Histories
4 elements of a history
Chief Complaint (CC), History or Present Illness (HPI), Review of Systems (ROS), Past, Family, and/or Social History (PFSH)
Chief complaint (CC)
Describes the symptom, problem, condition, diagnosis, physician recommended return, or other reason for the encounter stated in patient’s words
History of Present Illness (HPI)
Chronological description of development of patient present illness from first sign and/or symptom. Must be documented in the medical record by physician.
HPI Element Examples
Location (0n the body), Quality (hacking, throbbing, burning-characteristics), Severity (scale of 1-10;intensity), Duration (how long has the problem occurred), Timing (at night, throughout the day, in the morning-when does it occur), Context (when bending over-under what circumstances does it occur), Modifying factors (better when lying down (what circumstances make it better or worse), Associated signs and symptoms (weakness-what else is happening when it occurs).
Review of Systems (ROS)-definition
Inventory of by systems obtained by questioning the patient. They may have forgot to describe or seemed relatively unimportant. Must be reviewed by physician and document in medical record that has been reviewed to qualify as an ROS
Systems recognized by a Review of Systems (ROS)
Constitutional symptoms; Eyes (ophthalmologic); Ears, nose, mouth & throat (Otolaryngologic); Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Integumentary; Neurologic; Psychiatric; Endocrine; Hematologic/Lymphatic; Allergic/Immunologic
Past, Family, and/or Social History (PFSH) elements
Past history, Social History, Family History
-illnesses, operations, injuries, treatments;
-age appropriate review of activities. Marital status, employment, use of drugs-alcohol-tobacco, education, sexual history and other social factors.
Medical events in patient’s family that include health status or cause of death of parents, siblings, and children. Diseases of family members that may be hereditary.
3 of the elements of a history (HPI, ROS, and PFSH) are included in all patient encounters. (T/F)
What are the 4 history levels?
Problem focused, Expanded problem focused, Detailed, and Comprehensive.
Explain problem focused history
Focuses on the chief complaint & brief history of present problem of patient. Severity, duration, and/or symptoms of the problem or complaint.
Explain expanded problem focused history
Focus on chief complaint & brief history of present problem, also performs problem pertinent review of systems. Centers around specific questions regarding system involved in the presenting problem or cc. Covers the organ system most closely related to the CC or presenting problem and any related or associated organ system.
Explain a detailed history
Focused on CC, obtains an extended history of the present problem, and extended review of systems, and a pertinent PFSH
Explain a comprehensive history
Most complex of history types. Documents CC, obtains an extended history of the present problem, does a complete ROS, and obtains a complete PFSH.